Case Manager, ECM - Napa, United States - OLE Health

Description

POSITION TITLE: Case Manager, Enhanced Care Management (ECM)
DEPARTMENT: Behavioral Health

REPORTS TO: Behavioral Health Manager, Enhanced Care Management

LOCATION: Napa, CA

HOURS: Mon to Fri, 40 hours a week

Pay Range: $22.87 to $31.05/hr

About CommuniCare+OLE

Established in 2023, CommuniCare+OLE is the result of a union of two health centers with a deep roots in their respective communities and reputations for providing high-quality primary care to all, regardless of insurance or ability to pay: OLE Health of Napa and Solano Counties and CommuniCare Health Centers of Yolo County. Building on a legacy established by both organizations in 1972, CommuniCare+OLE is a network of federally-qualified health centers with 17 sites across Napa, Solano, and Yolo Counties. It offers comprehensive care, including medical, dental, behavioral health and substance use treatment, nutrition, optometry, pharmacy, care coordination, referrals, and enrollment assistance to more than 70,000 individuals, and no one is turned away due to lack of insurance, immigration status, or ability to pay. Many services are offered outside of its sites, including mobile health, home visiting, and community and school-based programs.

JOB SUMMARY:

Enhanced Care Management (ECM) is a whole-person, interdisciplinary approach to care that addresses the clinical and nonclinical needs of Members with the most complex medical and social needs through systematic coordination of services and comprehensive care management that is community based, interdisciplinary, high touch and person centered.Under the direction of the ECM manager and in conjunction with the ECM team, The Care Navigator will:

• Assist the ECM Member in navigating health care (medical, dental, behavioral health) and social service resource systems
• Provide ongoing care that is patient centered, outcome oriented, linguistically, and culturally appropriate
• Work to develop, implement, document, and maintain a care plan in conjunction with each ECM Member
• Assess and address social determinants of health
• Meet with the ECM Member in their homes, at a neutral location in the field or at CommuniCare+OLE sites
• Monitor and maintain Member enrollment status, release of information, care plans and ED/in-patient/long-term facility stays and readmission patterns for ECM Members

KNOWLEDGE OF WORK

Knowledge of Organizational Improvement Methods

Knowledge care navigation best practices

Knowledge of Federally Qualified Health Centers and the key health center principles and guidelines

DUTIES AND RESPONSIBILITIES

Provides community-based, high-touch, on-the-ground, face-to-face interactions with ECM Members. Assists clients in their homes, community, or clinic setting

Maintains a caseload of approximately 35-37 ECM Members

Collaborates with ECM team and CommuniCare+OLE staff including nursing, medical, dental, behavioral health, and care coordination to ensure the full spectrum of ECM services and benefits are implemented

Accompanies ECM Members to medical and other service-related appointments when necessary

Identifies and addresses social determinants of health

Develops a care plan and works with the ECM Member to formulate and execute realistic, time specific and measurable goals

Motivates ECM Members to be active and engaged participants in their health and overall wellbeing.

Assists ECM Members in utilizing community services, including scheduling appointments with social services agencies, and assisting with completion of applications for programs for which they may be eligible.

Acts to reduce cultural and socio-economic barriers between ECM Members and institutions.

Develops relationships with local community organizations to implement interventions that address social determinants of health

Monitors the Collective Medical software for ED/in-patient/long-term facility stays and readmission patterns

Maintains updated ECM Member status and uploads Releases of Information, and Care Plans onto Collective Medical

Abides by CommuniCare+OLE protocols regarding outreach staff and Member health and safety

Sustains accurate, detailed, and timely documentation of client interactions on the EHR.

Works closely with the Quality Improvement team to ensure patient interaction and data collection meet QI incentives/certifications.

Performs other duties as assigned

EDUCATION, EXPERIENCE, TRAINING

1. High school graduate or equivalent required. Bachelor's degree in related field preferred.

2. Experience working in a health care setting with FQHC experience preferred.

3. Experience working successfully with issues of substance use, mental health, criminal background, and other potential barriers to economic self-sufficiency.

4. Experience working with co-occurring disorders preferred.

5. Strong collaborative skills: ability to engage members of the care team, other disciplines, leadership, and external community partners effectively and appropriately.

6. Computer skills and knowledge of Microsoft Office required electronic health record.

7. Strong interpersonal and customer service skills required; ability to manage difficult and emotional patient situations.

8. Ability to adapt to change; approach challenges with an innovative and proactive attitude; and investigate resources.

9. Must have a valid California driver license, reliable personal vehicle and current personal auto insurance as required by law.

10. Must have initiative, strong analytical and problem-solving skills.

11. Must certify and remain current in CPR certificate.

12. Strong verbal and written communication skills required.

13. Bilingual (English/Spanish) required.

BENEFITS

• Medical, Dental, Vision Coverage
  • Employer covers 90% of employee medical, dental and vision premium and 50% of dependent premium
• 18 days of PTO (Vacation & Sick)
• 10 Paid Holidays + 1 Float Holiday
• 4% Employer Match for 403(b) retirement plan
• Tuition Reimbursement of up to $2,000 per Calendar Year for part-time and full-time employees (prorated per Full-Time Equivalent)
• Life & Accidental Insurance Coverage
• Employer contribution for Health Savings Account
• Flexible Spending Account (FSA) and Limited FSA Options